Pleural Diseases Treatment Overview

Study Notes

Pleural Diseases Treatment

Thoracocentesis:
- Used primarily for pleural effusion.
- Involves needle insertion at the upper border of the rib below the scapular line, typically under the 10th rib.
- Must be performed under strict aseptic conditions.
- Potential complications include hemothorax, pneumothorax, neurogenic shock, and pulmonary edema.
Intercostal Chest Tube (Under Water Seal):
- Indicated for pneumothorax (open, bilateral, or tension), empyema, and hemothorax.
Tension Pneumothorax:
- Considered a medical emergency.
- Requires immediate insertion of a wide-bore needle in the 2nd intercostal space for decompression, followed by an intercostal chest tube.
- Supportive care includes oxygen and analgesics.

Bronchial Asthma

Aetiology:
- Characterized by bronchial narrowing due to bronchospasm, inflammatory infiltrate (especially eosinophils), and mucus plugs.
Pathophysiology:
- Can be classified into extrinsic (allergy-related) or intrinsic (bronchial hyper-reactivity) asthma.
Clinical Picture:
- Patients are often symptom-free between attacks.
- Attacks typically occur at night or early morning, manifesting as wheezing, non-productive cough, and dyspnea.
- End of attack may produce small viscid sputum.
Signs During Attack:
- Inspection reveals bilateral restricted respiratory movement.
- Palpable rhonchi and central trachea on palpation.
- Percussion shows bilateral hyper-resonance.
- Auscultation reveals harsh vesicular breathing with prolonged expiration and generalized rhonchi.
Complications:
- Respiratory complications include status asthmaticus and respiratory failure.
- General complications can arise from treatments (e.g., steroids leading to diabetes mellitus, hypertension).
- Chronic cough complications include myositis, rib fractures, pneumothorax, hemoptysis, and extra-thoracic issues like puffy eyelids and hernias.
Investigations:
- Sputum examination shows increased eosinophils.
- Eosinophilia observed in blood tests.
- Elevated serum IgE levels in extrinsic asthma.
- Skin prick tests identify causative antigens.
- Chest X-ray may show signs of hyperinflation.
- Pulmonary function tests indicate obstructive hypoventilation.
Treatment:
- Short-acting B2-agonists (e.g., Salbutamol) serve as relievers.
- Inhaled corticosteroids (ICS) and long-acting B2-agonists (LABA) serve as controller medications.
- Oral leukotriene receptor antagonists (e.g., Montelukast) and oral or parenteral steroids (e.g., prednisolone) are also employed.
- IgE monoclonal antibodies (e.g., Omalizumab) may be useful for specific patients.

Pneumonia

Clinical Picture:
- Common symptoms include fever, anorexia, headache, malaise, cough, dyspnea, and rusty sputum.
Signs:
- Physical examination may reveal limited respiratory movements, increased tactile vocal fremitus on palpation, dullness on percussion, and bronchial breathing with crepitations on auscultation.
Special Types of Pneumonia:
- Staphylococcal Pneumonia: Caused by Staphylococcus aureus; treated with nafcillin or vancomycin.
- Fridlander's Pneumonia: Caused by Klebsiella, especially in immunosuppressed patients; treated with ceftriaxone.
- Pneumocystis Jiroveci Pneumonia: Common in AIDS patients; treated with Septrin or pentamidine.
- Mycoplasma Pneumonia: Mostly affects children and young adults, can lead to systemic infections; treated with macrolides.
- Legionella Pneumonia: Caused by Legionella pneumophila from contaminated water; diagnosed by urine antigen test and treated with macrolides.
Viral Pneumonia:
- Atypical pneumonia caused by various viruses, including influenza, CMV, EBV, RSV, measles, and coronaviruses like SARS.